Please complete and email this form to the COVID-19 Vaccine Program at least 15 days before your requested day of disenrollment from program participation.
Providers are required to notify the Program at least 15 days before the site intends to terminate the CDC COVID-19 Vaccine Provider Agreement and disenroll from the PA COVID-19 Vaccine Program. Please understand that until the site receives approval and the Division of Immunizations can make arrangement for relocating the COVID vaccines, it must:
- Store COVID vaccines appropriately as per the program's requirements.
- Be accountable for all COVID-19 vaccines obtained from the state allocation.
After the review of the application, the primary and secondary vaccine coordinator at the site will be contacted by the COVID-19 Vaccine Program representative via email.
Instructions:
- Complete this form in its entirety and provide CEO/CMO signature and date.
- Submissions with blank fields will be returned for corrections and will cause delay in processing the request.
- Email completed form to RA-DHCOVIDVax@pa.gov.
- Once the form is processed by the DOH, you will receive a confirmation email from RA-DHCOVIDVAX@pa.gov.